On-line Private Retreat Registration Form

Private Retreat Registration Form

A deposit is required to secure your retreat date. Deposits are non-refundable. As a courtesy, Loyola on the Potomac will transfer your deposit one time and within one year to another retreat for you or another retreatant, per your approval. After one year, money not utilized for a retreat will be recorded as a gift to Loyola on the Potomac. Thank you.

Name*

PrefixFirstLast

Gender

Male

Female

Address*

State*

Zip:*

Preferred Phone:*

Alternate Phone:

(Optional) (Opcional)

Email*

Parish

Have you ever been to Loyola on the Potomac before:*

Yes

No

How did you hear about us:

Special Needs (Necesidades especiales):

Please describe any health concerns (physical or psychological), special needs, or dietary allergies that we should be aware of.

Emergency Contact:*

Preferred Phone:*

Alternate Phone:

(Optional)

This form is to register for Four, Five or Eight Day Retreats only. For other options contact our office at (301) 392-0801.
You can select the deposit payment of $115 or the full cost of the retreat.